New Family Intake Form
Parent Name
*
First Name
Last Name
Kid's Name
*
First Name
Last Name
Kid's Name
First Name
Last Name
Kid's Name
First Name
Last Name
Number of Kids
*
Age(s) of Child
*
Are any in school?
*
Yes
No
Grade(s)
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Desired date to start services
*
-
Month
-
Day
Year
Date
Nanny or babysitting service
*
Nanny
Babysitting
Are you needing full-time or part-time service?
*
Full-Time
Part-Time
Few Hours (1 day)
Overnight
Travel
Please select the applicable one
*
I would like to come to your place
I want you to come to my house
Does not matter
Other
Explain "Other"
Any pets in home?
*
Yes
No
If so, what kind?
How many? (if applicable)
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Family Specific Needs
Are you needing Special Needs care?
*
Yes
No
What is the special need?
What are some things that you are looking for your caregiver to do? Ex: meal time, nap, potty train etc.
*
Please be as specific as possible, so we are able to match you with an appropriate caregiver.
Are there any behavioral challenges that we should know about?
*
Will there be any need for your care giver to transport? Ex: School, Dr. appts, child classes etc.
*
Yes
No
Maybe
Homework assistance?
*
Yes
No
Maybe
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Any allergies to anything? If so what ingredient.
*
No
Yes
Please list child's name for allergy
Please give details, if needed.
If you have any other questions or concerns for us, please list them below.
What are the desired hours? Ex: 9-5pm
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Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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